Have you come across any thoughts or ideas that would suggest any possible need for modification with MBT?

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Ethics

According to the University of Surrey’s ethics flowchart (see Appendix E), ethical approval was not considered necessary for this study. The flowchart requires that psychological research with human participants is guided by certain core principles, and that ethical approval is sought when the following criteria are met:

a) Procedure(s) involving any risk to a participant’s health (both psychological and physical); b) Surveys, questionnaires and any research, the nature of which might be offensive, distressing or deeply personal for the particular target group;

c) Proposals for research that intends to use undergraduate students as participants;

d) Research proposals to be carried out by persons not connected with the University, but wishing to use staff or students as participants;

e) Proposals wishing to use children under the age of 16.

These core principles of the flowchart were discussed substantially and evaluated with the research supervisor. Additionally, ethical matters were further discussed with the University’s senior qualitative research lecturer and deemed not necessary. As a result, all participants were aged between 35 and 62 years, all highly trained accredited MBT therapists from diverse training backgrounds (psychotherapists & clinical psychologists).

As the participants were mature consenting adults, ethically aware, self-care minded, not vulnerable and not recruited from the Surrey academic institution, ethical approval was not deemed necessary for the current study. Although ethical approval was not required for the research, ethical considerations and possibilities were still deemed significantly important. The researcher’s ethical obligations and potential ethical implications were carefully considered prior to the study. However, as with any study consisting of human participants, ethical considerations are complex and have multifaceted implications for the practice and research in the given area and counselling psychology (Cross & Wood, 2015).

Although no ethical approval was required from the institution’s ethics committee, the research study took care to adhere to the BPS Code of Human Research Ethics (BPS, 2009) and paid special attention to the Division of Counselling Psychology (DoCP) Professional Practice Guidelines (BPS, 2013). The Code of Human Research Ethics (BPS, 2009) requires

137 psychological research with human participants to be guided by certain core principles such as respect for autonomy and dignity of a person; scientific value; social responsibility; and maximising benefit and minimising harm (Code of Human Research Ethics, 2009). Adherence to these core principles is considered essential when conducting psychological research with human participants, and there is a clear duty for the psychologist towards the participants. An indispensable component of the guided principles in the Code of Human

Research Ethics (BPS, 2009) is the psychologist’s respect for the participants’ dignity and

autonomy, whereby caution is applied to making rational judgements about any actions in the course of conducted research which will have an impact on the autonomy and dignity of the participants.

Other protocols required by the Code of Human Research Ethics (BPS, 2009) are risk assessment, obtaining valid consent, debriefing participants and confidentiality in line with the Data Protection Act (1998). Congruent with the Code of Human Research Ethics (BPS, 2009) and the Data Protection Act (UK Legislation, 1998), all participants in the study were debriefed with regards to the nature and value of the research, and had the right to withdraw from the study at all times, if they wished to do so. Additionally, a consent form was given to and signed by the participants on the day the interview was conducted, which provided details regarding confidentiality and the right to withdraw from the study at any time if they wished to do so. Furthermore, all data recorded was saved on an encrypted USB drive, kept securely, and destroyed after transcription. Transcripts were kept under pseudonyms in order to protect the identity of the participants.

In addition, the researcher always aimed to guide his research model according to the values expressed in counselling psychology. This was conducted by following the Division of Counselling Psychology (DoCP) Professional Practice Guidelines (BPS, 2013). The DoCP was used in addition to the BPS’s Code of Conduct, Ethical Principles and Guidelines and

Code of Human Research Ethics, which both set the minimum standard for which behaviour

should not cross both in generic professional practice and in research ethics with human participants. One of the core principles of counselling psychology (CP) promotes a phenomenological model of therapeutic practice, and is significantly influenced by a strong psychotherapeutic tradition (DoCP, 2013). The researcher aimed to design his research model in accordance with the DoCP principles. This was done as the researcher always tried to engage with the phenomenology of the participants, as well as respecting their perspectives, and kept an anti-discriminatory attitude to the emerging narratives.

138 Although ethical approval was not deemed necessary, the current research study was not excluded from ethical possibilities due to the potential sensitive nature of the research topic and the methodological approach chosen. The study therefore followed the Code of Human

Research Ethics, the DoCP Professional Practice Guidelines and also provided participants

with the opportunity to give valid informed consent, assured confidentiality and debriefing opportunities.

As the study touched on potentially complex issues by exploring the therapist’s experience of conducting mentalization based therapy (MBT) with borderline personality disorder (BPD) clients and their understanding of the model, ethical challenges were probable. The exploration of topics such as personal experiences of MBT and working with patients who have complex presentations such as BPD has the potential to create discomfort in participants and this therefore needed to be considered whilst conducting the study. As BPD presentation often includes factors such as suicidality, emotional switching points and boundary pushing behaviours, even the most highly trained therapists can experience emotional distress. Many studies exploring mental health practitioners experiences of working with BPD presentation reveal attitudes and experiences to be predominantly negatively orientated and rather difficult (Bowers & Allan, 2006; Trealor & Lewis, 2015). As the research touched on possible difficult experiences therapists might have had with their BPD clients, the interview process had the potential to cause emotional discomfort and distress in the participants. However, as the participants were mature, consenting and had several years of clinical experience working with BPD presentation, it was felt that they had greater self-awareness to stop the interview should they feel distressed. Therefore, the researcher did not consider the interview process likely to cause serious emotional harm or distress to the participants, but made himself available to react to any queries or concerns the participants might have. Furthermore, some ethical awareness was also given to the absent clients, whom the participants were including in the interview conversations. Consequently, awareness of both the participants and clients confidentiality was taken into consideration as conversations around a particular vulnerable client group was evident during the interviews.

The researcher, himself a trainee counselling psychologist, strived to minimise participant discomfort and emotional distress when talking about possible difficult experiences they might have had with BPD clients by using gentle introductory questions and using his basic counselling skills, such as empathy, genuineness and providing a safe environment. This is

139 known to be able to minimise participant distress when dealing with difficult and sensitive topics and experiences (Sen Gupta, 1998; Abrahams, 2007).

Furthermore, qualitative research can expose the researcher to certain ethical dilemmas due to the fluidity and inductive uncertainty of the research method (Birch, Miller, Mauthner & Jessop, 2012). The complexities of utilizing a qualitative approach to research private lives, perspectives and world views can raise multiple ethical issues for researcher. This cannot exclusively be solved by the application of abstract rules and guidelines being put forward by ethics committees in academic institutions and the Code of Human Research Ethics (BPS, 2009). However, the researcher was aware of his ethical obligations at all times, and if any distress was observed the participants would be offered a break, the potential to continue the interview another day, or could completely withdraws from the research at any time.

Data Analysis

The study employed IPA methodology suggested by Smith, Flowers & Larkin (2009), and transcripts were analysed for emerging super-ordinate and respective sub-themes. Initially, all interviews were read through numerous times in order to increase familiarity with the data, and preliminary ideas about the data and any interpretations were noted separately. Additionally, a table was developed containing three columns: the middle column included the original transcript, the right column included the exploratory comments, and the left column included emergent themes (see Smith, Flowers & Larkin, 2009 for guidance). This constituted the first phase of the data analysis that consisted of descriptive, linguistic, and conceptual comments around the data obtained. A similartable was developed for each of the five interview transcripts, and further emergent themes were then gathered into clusters of themes demonstrating possible higher order themes and accompanying subthemes, whereupon emergent themes were then transferred into a separate table. Possible higher order themes throughout all of the interviews were then associated with and gathered into super- ordinate and sub-themes, which were displayed in a final table (see Table 2).

The unique characteristics of IPA include the fact that it is informed by the researcher playing a communicative part in the dynamic interview process, interpreting and making sense of the participants’ narratives. The researcher’s experiences and sensitivities also play a significant part in the development of themes and the process of interpretation, which is defined as a ‘double-hermeneutic’ process by Smith (1996). However, by frequently attending research

140 supervisory meetings, the researcher consequently checked the validity of emerging themes and was in conversation with the supervisor in order to avoid bias. Additionally, the research adopted the following guidelines from Elliot, Fisher, & Rennie (1999):

1) “Grounding in examples: Participants’ quotations are involved within the analysis section of this report; the potential reader can draw on their own viewpoints on the correctness of the analytic interpretations of the data”;

2) “Providing credibility checks: give methods for checking the results such as checking with research supervisor”;

3) “Coherence: understanding is presented in a 'narrative' or other structure that maintains the nuances of meaning through integration of the data and answering the research question”; 4) “Resonating with readers: the account provides "resonance" or meaning for the reader/reviewer as an accurate portrayal of the phenomenon”.

Moreover, the researcher’s personal interest in the MBT model and BPD comes from personal experience of having gone through the basic skills training at the Anna Freud Centre and having to struggle with BPD within the family, as well as the empowering experience of working with the complex cases team for BPD within an NHS setting. Hence, continuous awareness of the author’s own level of subjectivity during each phase of the research had to be preserved, due to the IPA being a significantly interpretative procedure.

Results

Following the research question of how MBT therapists make sense of the MBT model, the analysis of the data identified four distinctive but interrelating super-ordinate themes, each with their respective sub-themes. The first super-ordinate theme identified how participants conceptualised mentalization. The second related super-ordinate theme explored how participants experienced the distinctiveness of the MBT model and how it was also similar to other modalities. The third super-ordinate theme emerging identified how the participants experienced and conceptualised BPD, with the final super-ordinate theme examining and identifying the experience of how MBT had an impact on BPD presentation. These super- ordinate themes and the corresponding sub-themes are all summarised in Table 2. A further

141 in-depth exploration and analysis of each super-ordinate theme will be presented in the following section of this report.

Table 2. Summary of Themes

Super-ordinate Themes Sub-themes

1. Conceptualising Mentalization

2. Distinctiveness and similarities of the MBT model

3. Conceptualising BPD

4. MBT and its impact on BPD

Difficult to conceptualise Wide & broad concept

Conception broadened following reflection

The ability to reflect and understand one’s own mind and the mind of others

Assisting reflection in a relational context Stimulating reflective thinking

Working with the present Excluding transference techniques

Liberating and freeing when working with BPD A stance rather than a model

Overlapping other modalities

Difficult patient group Lack of mentalizing capacity Concrete thinking

Described as a ‘mindless bottle’ of person

Described as varied, but positive Reducing self-harm

Assists reflective thinking Precursor for other therapies Perception of MBT training